HUD

INTENT TO APPLY

2016FOR NEW REALLOCATED AND/ORRENEWALFUNDING

(This is to be completed for each project seeking funding and is due to the CoC Coordinator on

July 14, 2016@ 5:00 p.m.at United Way of Saginaw County; 100 S. Jefferson Avenue; Saginaw, MI. ALL INFORMATION REQUESTED IS TO BE PROVIDED. LATE OR INCOMPLETE SUBMISSIONS WILL NOT BE CONSIDERED ELIGIBLE FOR FUNDING.

FUNDING SOURCE: ( ) HUDPROGRAM NAME: ______

AGENCY INFORMATION:

AGENCY NAME:

PROGRAM LOCATION:

CONTACT PERSON NAME:

CONTACT PERSON EMAIL:

CONTACT PERSON PHONE AND/OR CELL PHONE:

ARE YOU A MEMBER OF SC-CHAP IN GOOD STANDING (You have participated in a minimum of 75% of CoC Meetings) ( ) YES ( ) NO

APPLICANT AND SPONSOR STATUS:

( ) AGENCY IS APPLICANT AND SPONSOR

( ) AGENCY IS SPONSOR (indicate the applicant :______)

PROGRAM FUNDING INFORMATION:

( ) RENEWAL – 1 year renewal amount total (includes administration):______

( ) NEW REALLOCATED– indicate total request amount (includes administration):______

SERVICES INFORMATION:

  • Give a brief description of the service(s) to be provided:

How many people per year will benefit if your project is funded?

  • What population is to be served:
  • Number of homeless individuals:
  • Number of homeless families:
  • Estimated total homeless served (include all adults and children):
  • Indicate beds or slots that are designated for chronic homeless:

OTHER INFORMATIONREQUIRED FOR SUBMISSION (indicate if this is attached and if not why not):

PLEASE NOTE: If you are submitting requests for multiple projects only ONE copy of the information below is required to be submitted.

( Y/N ) Indicate if the agency is currently prohibited from applying for HUD or MSHDA funding. If yes, provide documentation.
( ) Agency current audit(if required by law or funding sources) or current financial statement if the audit is not required.
( ) Current Form 990 (if applicable).

( ) Evidence of 501c3 status.
( ) HUDmonitoring reports, corrective action plans, and responses to corrective action plans of the program

seeking funding during the mostrecent grant period (renewals only).

( ) Recaptured Funds ( ) Yes ( ) No: Provide proofof proper spend down of funds. SUBMIT THE PROJECT BUDGET SHOWINGSPEND DOWN FROM PREVIOUS YEAR(eLOCCS report).

( )Last 3 governing board meeting minutes and list of Board of Directors and contact information(NEW HUD Funding Requests ONLY)

( ) MOST RECENT APR available for this project (Within the Last 12 Months)

______

Signature of the CEO or Executive Director Date